<div style='margin-bottom: 10px'>
	<table cellpadding="0" cellspacing="0" class='grid' style='width: 870px'>
    	<tr>
			<th style='width: 30%'>{translate}Doctor{/translate}</th>
			<th style='width: 30%'>{translate}Requested time{/translate}</th>
			<th style='width: 40%'>{translate}Diagnosis{/translate}</th>
		</tr>
		<tr class='last'>
	        <td class='form_input' valign='top'>
	            <select id="doctorId" name="doctorId" style="width: 100%;">
	                <option id="empty" value="0">{translate}Select doctor{/translate}</option>
	                {html_options options=$doctorList}
	            </select>
	        </td>
	        <td class='form_input' valign='top'>
	           <input name="created_{$datePart_0}" id="created_{$datePart_0}" type="text" value="{$createdDate.0}" style="width: 30px;">
	           <input name="created_{$datePart_1}" id="created_{$datePart_1}" type="text" value="{$createdDate.1}" style="width: 30px;">
	           <input name="created_{$datePart_2}" id="created_{$datePart_2}" type="text" value="{$createdDate.2}" style="width: 56px;">
	           <input name="createdTime" id="createdTime" type="text" value="{$createdTime}" style="width: 56px;"/>
	           <br/><span class="label" style="width: 21px; color: #AAA;">({$datePart_0}-{$datePart_1}-{$datePart_2} hh:mm)</span>
	        </td>
	        <td class='form_input' valign='top'>
	            <textarea style="width: 100%;" name="diagnosis" id="diagnosis"></textarea>
	        </td>
	    </tr>
	</table>
</div>